Adult Hematopoietic Stem Cell Transplantation Research Articles

Immune reconstitution is preserved in hematopoietic stem cell transplantation coadministered with regulatory T cells for GVHD prevention

AbstractRecipient-specific regulatory T cells (rsTreg) can prevent graft-versus-host disease (GVHD) by inhibiting donor T-cell expansion after hematopoietic stem cell transplantation (HSCT) in mice. Importantly, in adult humans, because of thymus involution, immune reconstitution during the first months after HSCT relies on the peripheral expansion of donor T cells initially present in the graft. Therefore, we developed a mouse model of HSCT that excludes thymic output to study the effect of rsTreg on immune reconstitution derived from postthymic mature T cells present within the graft. We showed that GVHD prevention with rsTreg was associated with improvement of the limited immune reconstitution compared with GVHD mice in terms of cell numbers, activation phenotype, and cytokine production. We further demonstrated a preserved in vivo immune function using vaccinia infection and third-party skin-graft rejection models, suggesting that rsTreg immunosuppression was relatively specific of GVHD. Finally, we showed that rsTreg extensively proliferated during the first 2 weeks and then declined. In turn, donor Treg proliferated from day 15 on. Taken together, these results suggest that rsTreg GVHD prevention is associated with improved early immune reconstitution in a model that more closely approximates the biology of allogeneic HSCT in human adults.

Incidence and Outcome of Adenovirus infection in Adult Allogeneic Hematopoietic Stem Cell Transplant Recipients

Incidence and Outcome of Adenovirus infection in Adult Allogeneic Hematopoietic Stem Cell Transplant Recipients

The Neuropsychological Course of Acute Delirium in Adult Hematopoietic Stem Cell Transplantation Patients

Although delirium is a common medical comorbidity with altered cognition as its defining feature, few publications have addressed the neuropsychological prodrome, profile, and recovery of patients tested during delirium. We characterize neuropsychological performance in 54 hemapoietic stem cell/bone marrow transplantation (BMT) patients shortly before, during, and after delirium and in BMT patients without delirium and 10 healthy adults. Patients were assessed prospectively before and after transplantation using a brief battery. BMT patients with delirium performed more poorly than comparisons and those without delirium on cross-sectional and trend analyses. Deficits were in expected areas of attention and memory, but also in psychomotor speed and learning. The patients with delirium did not return to normative "average" on any test during observation. Most tests showed a mild decline in the visit before delirium, a sharp decline with delirium onset, and variable performance in the following days. This study adds to the few investigations of neuropsychological performance surrounding delirium and provides targets for monitoring and early detection; Trails A and B, RBANS Coding, and List Recall may be useful for delirium assessment.

Prospective Evaluation of Allogeneic Hematopoietic Stem-Cell Transplantation From Matched Related and Matched Unrelated Donors in Younger Adults With High-Risk Acute Myeloid Leukemia: German-Austrian Trial AMLHD98A

To assess the impact of allogeneic hematopoietic stem-cell transplantation (HSCT) from matched related donors (MRDs) and matched unrelated donors (MUDs) on outcome in high-risk patients with acute myeloid leukemia (AML) within a prospective multicenter treatment trial. Between 1998 and 2004, 844 patients (median age, 48 years; range, 16 to 62 years) with AML were enrolled onto protocol AMLHD98A that included a risk-adapted treatment strategy. High risk was defined by the presence of unfavorable cytogenetics and/or by no response to induction therapy. Two hundred sixty-seven (32%) of 844 patients were assigned to the high-risk group. Of these 267 patients, 51 patients (19%) achieved complete remission but had adverse cytogenetics, and 216 patients (81%) had no response to induction therapy. Allogeneic HSCT was actually performed in 162 (61%) of 267 high-risk patients, after a median time of 147 days after diagnosis. Graft sources were as follows: MRD (n = 62), MUD (n = 89), haploidentical donor (n = 10), and cord blood (n = 1). The 5-year overall survival rates were 6.5% (95% CI, 3.1% to 13.6%) for patients (n = 105) not proceeding to HSCT and 25.1% (95% CI, 19.1% to 33.0%; from date of transplantation) for patients (n = 162) receiving HSCT. Multivariable analysis including allogeneic HSCT as a time-dependent covariable revealed that allogeneic HSCT significantly improved outcome; there was no difference in outcome between allogeneic HSCT from MRD and MUD. Allogeneic HSCT in younger adults with high-risk AML has a significant beneficial impact on outcome, and allogeneic HSCT from MRD and MUD yields similar results.

GVHD after unrelated cord blood transplant in children: characteristics, severity, risk factors and influence on outcome

We reviewed our experience in 79 children who had unrelated cord blood transplant (UCBT) between 1996 and 2007 with a major focus on GVHD, comparing both traditional and National Institute of Health (NIH) criteria. The cumulative incidence (CI) of acute GVHD (aGVHD, by day +100) was 0.42 for grade II-IV and 0.22 for grade III-IV. The CI of all aGVHD (NIH, that is, no time limit) at 1 year was 0.45 for grade II-IV and 0.32 for grade III-IV. Infused CD34 cell dose (>1 × 10(5)/kg), pretransplant bacterial infection and nonmalignant disorders were risk factors for grade II-IV aGVHD on univariate analysis. Infused CD34 cell dose remained significant on multivariate analysis. At 1 year, the CI of chronic GVHD (cGVHD) using the Seattle criteria was 0.27, whereas that for cGVHD (NIH) was 0.08. By NIH criteria, the classic form of cGVHD was uncommon (5%) after UCBT. Instead, the acute (71%) and overlap (24%) GVHD variants predominated. Grade II-IV aGVHD was a significant risk factor for cGVHD by both Seattle and NIH criteria. We conclude that GVHD after day +100 after UCBT typically carries features of aGVHD. Moreover, and in marked contrast to adult unrelated donor hematopoietic stem cell transplantation, the GVHD observed in this series did not adversely affect survival.

Poor outcome of adenovirus infections in adult hematopoietic stem cell transplant patients with sustained adenovirus viremia

The outcome of adenovirus (ADV) infections in adult hematopoietic stem cell transplant (HSCT) patients remains poorly characterized. We studied 14 adults and 3 children, who had undergone HSCT and had developed ADV viremia. Peak ADV DNA levels were significantly higher in patients with ADV diseases than in those without (P=0.03). All children survived the ADV infections. Among the 14 adult HSCT patients, 11 were treated with cidofovir, 2 with ribavirin, and 1 did not receive antiviral treatment. Six of the 13 (46%) treated patients developed ADV diseases and 3 of them (23%) died of ADV infections. Sustained viremia (≥3 positive polymerase chain reaction assays during follow-up) was detected in all patients who finally died of ADV infections. However, 2 adults having had transient ADV viremia either survived or died of diseases other than ADV infections. Our study indicates that the outcome of adult HSCT patients with sustained ADV viremia may be poor, even for those who have received anti-ADV treatment.

Use of Cytomegalovirus Intravenous Immune Globulin for the Adjunctive Treatment of Cytomegalovirus in Hematopoietic Stem Cell Transplant Recipients

To describe the characteristics and clinical outcomes of hematopoietic stem cell transplant (HSCT) recipients who received adjunctive cytomegalovirus intravenous immune globulin (CMV-IVIG) for probable or proven CMV disease. Retrospective cohort study. Large, university-affiliated, tertiary-care medical center. Thirty-five adult HSCT recipients who received at least one dose of CMV-IVIG for adjunctive treatment of probable or proven CMV disease between January 1, 1999, and December 31, 2007. All-cause mortality at hospital discharge was the primary outcome. All patients received an allogeneic HSCT. Twenty-six patients (74%) had pneumonitis, nine (26%) had enteritis, and 29 (83%) had CMV viremia. All patients received concomitant antiviral therapy; 31 (89%) received ganciclovir, and 14 (40%) received foscarnet. All-cause mortality at hospital discharge was 49% (17 patients). Patient characteristics associated with mortality included requiring intubation for CMV pneumonia (11 [79%] of 14 nonsurvivors vs 3 (25%) of 12 survivors, p=0.016) and earlier disease onset after HSCT (median 48 days for nonsurvivors vs 106 days for survivors, p<0.001). In the multivariate analysis, only requiring intubation for CMV pneumonia remained a significant risk factor for increased mortality. A low rate of adverse events was attributed to CMV-IVIG, with mild hypertension (two patients [6%]) and erythema and chills (one patient [3%]) being the most common. The mortality rate in our study population was similar to previous reports in the literature and may be somewhat lower than rates reported with antiviral monotherapy. Our analysis suggests that factors associated with mortality include the need for intubation and, possibly, earlier onset of CMV disease after HSCT. Treatment with CMV-IVIG appears to be well tolerated in HSCT recipients. These findings support further trials of CMV-IVIG efficacy in this setting.

Geographic access to hematopoietic stem cell transplantation (HSCT).

e16517 Background: Hematopoietic Stem cell transplantation (HSCT) has been used with considerable success in the management of patients with otherwise incurable malignant and nonmalignant conditions. Transplantation is a resource-intensive endeavor that requires specialized personnel and equipment available through a limited number of institutions. Transplant patients tend to undergo prolonged hospitalizations and require frequent follow up visits. The optimal geographic distribution of transplant centers has not been determined, in fact the current distribution of centers relative to geographic area and population is unknown. Methods: Using the 2008 county level census estimate data, the proportion of the population living within a combined statistical area (CSA) with a transplant center or within an hour-travel of one was determined. Combined Statistical Areas, as defined by the Office of Budget and Management (OMB), comprise two or more adjacent Metropolitan or Micropolitan Statistical Areas that have moderate social and economic ties as measured by commuting. Travel time was determined by the shortest driving time between county centroids and the closest HSCT center, regardless of state lines. The list of adult HSCT centers was obtained from the National Marrow Donor Program (NMDP). Results: In 2009, there were 102 adult HSCT centers listed by the NMDP in the United States. An estimated 60.92% of the US population have easy access to a HSCT center as defined above. Regional access was as follows: Northeast, 78.26%; West, 64.16%; Midwest, 57.03%; and South, 52.65%. Nine states have no centers, while 10% of centers are located in just 2 counties; Philadelphia, Pa and Cook, Il. Conclusions: 60.92% of the U.S. population have easy geographic access to a HSCT center, however, there is both state and regional variation in access to these centers. The greatest proportion of the population with access was highest in the Northeast and lowest in the South. There is need for further research to determine the impact of geographic access in rates of transplantation, outcomes and the economic and social impact of lack geographic of access. No significant financial relationships to disclose.

Detection and Control of a Nosocomial Respiratory Syncytial Virus Outbreak in a Stem Cell Transplantation Unit: The Role of Palivizumab

Respiratory syncytial virus (RSV) is a common community-acquired virus that causes upper and lower respiratory tract infections in children, hematologic malignancy patients, and hematopoietic stem cell transplant (HSCT) recipients. Nosocomial transmission of RSV in immunocompromised patients can significantly affect morbidity, mortality, and duration of hospitalization. Stringent infection control measurements are needed to control further hospital transmission. Prophylactic palivizumab was found to result in a significant reduction in hospitalization rates in high-risk children. In this article, we report a nosocomial outbreak of RSV in an adult HSCT unit (4 pods) from January 16 to February 4, 2004, including the infection control interventions used and the prophylactic administration of palivizumab in high-risk patients. Active surveillance identified 5 cases, a substantial increase from previous seasons (2 or 3 cases per season). All infected patients were isolated to 1 nursing pod and placed on contact isolation. All patients on the HSCT unit underwent rapid RSV antigen screening using nasal washes; this was repeated 1 week later, and 1 additional RSV case was identified. Patients identified to be at increased risk for RSV infection received prophylactic palivizumab. Routine screenings of the staff and visitors were undertaken. All patient and visitor areas were thoroughly cleaned with bleach. We educated health care workers about RSV transmission, highlighting proper hand hygiene and contact precautions. Four of 6 patients with RSV infection developed RSV pneumonia, and 2 of these patients died. Staff and visitors with upper respiratory symptoms were screened, and all were negative for RSV. Prophylactic palivizumab was administered in 16 patients who tested negative for RSV, but were considered to be at increased risk for RSV infection. None of these patients developed RSV infections. An RSV outbreak was controlled using prompt preventive measures, including cohorting patients, with a dedicated health care staff; contact isolation of patients; strict adherence to hand hygiene; and screening of visitors, family members, and health care staff for upper respiratory infection symptoms. Immunoprophylaxis with palivizumab, administered to high-risk patients, complemented strict infection control intervention. Thus, the role of palivizumab in the control of RSV hospital outbreaks merits further investigation.

Risk factors for fungal pulmonary infections in hematopoietic stem cell transplantation recipients: the role of iron overload

Fungal pulmonary infections (FPIs) are frequent causes of mortality in hematopoietic stem cell transplantation (HSCT) recipients. Determination of the specific risk factors may improve the prognosis. The aim of this study was to evaluate the risk factors of FPIs due to HSCT. Patient history, physical examination, chest X-rays and the consultation records of the pulmonary disease department which were a part of the routine evaluation before and at first, third, sixth, ninth and twelfth months of HSCT were retrieved in 148 adult HSCT recipients. Results of the high-resolution computed tomography, fiber-optic bronchoscopy and the microbiological data were also included. FPI was diagnosed in 22 patients (14.9%). Multivariate analysis showed that increased ferritin levels (>1000 ng/ml; OR: 3.42, 95% CI 1.03-11.42, P=0.045) and the development of sinusoidal obstruction syndrome (SOS; OR: 5.09, 95% CI 1.53-16.90, P=0.008) were significant risk factors for FPIs. The sensitivity and specificity of ferritin >1000 ng/ml for the prediction of FPIs were 67 and 70%, respectively. There was a positive correlation between the increased risk of FPIs and pretransplantation ferritin levels (r=0.413, P<0.001) and increased ferritin levels and SOS (r=0.331, P<0.001). Increased pretransplantation ferritin levels and development of SOS are predictive factors of FPIs during HSCT.

Strong Association between Respiratory Viral Infection Early after Hematopoietic Stem Cell Transplantation and the Development of Life-Threatening Acute and Chronic Alloimmune Lung Syndromes

Alloimmune lung syndromes (allo-LS), including idiopathic pneumonia syndrome, bronchiolitis obliterans syndrome, and bronchiolitis obliterans organizing pneumonia, are severe complications after hematopoietic stem cell transplantation (HSCT). In our cohort of 110 pediatric patients, 30 had allo-LS (27.3%), 18 with ideopathic pneumonia syndrome and 12 with bronchiolitis obliterans syndrome. Multivariate analysis showed that respiratory viral infection early after HSCT is an important predictor for the development of allo-LS (P <.0001). This was true for all viruses tested. In multivariate analysis, allo-LS was the only predictor for higher mortality (P = .04). Paradoxically, prolonged administration of immunosuppressive agents because of acute graft-versus-host disease had a protective effect on the development of allo-LS (P = .004). We hypothesize that early infection of the respiratory tract with a common cold virus makes the lungs a target for alloimmunity.

Hematopoietic Stem-Cell Transplantation for Adults with Sickle Cell Disease

Sickle cell disease is an inherited hemoglobinopathy that affects over 70,000 persons in the United States. Sickle hemoglobin (hemoglobin S) polymerizes under conditions of hypoxemia and acidosis, thereby perturbing the integrity of the erythrocyte. This alteration causes hemolysis and vaso-occlusion. Recently, two clinical phenotypes of sickle cell disease have been described. In the hemolysis-associated phenotype, severe anemia, leg ulcers, and pulmonary hypertension are characteristic. In the vaso-occlusion–related phenotype, episodes of pain, acute chest syndrome, splenic infarction, stroke, and avascular necrosis of joints predominate. Endothelial dysfunction and vasculopathy also occur in sickle cell disease. Although its course is unpredictable, the disease . . .

Molecular epidemiology of KI and WU polyomaviruses in infants with acute respiratory disease and in adult hematopoietic stem cell transplant recipients.

Polyomaviruses KI (KIPyV) and WU (WUPyV) were described recently in children with acute respiratory disease. The pathogenic potential of these human viruses has not been determined completely, but a correlation between immunosuppression and virus reactivation has been suggested. In the present study, the association between KI/WUPyV infection and immunosuppression was investigated using sequential nasopharyngeal aspirates from asymptomatic adult hematopoietic stem cell transplant recipients. In parallel, an investigation on the WU/KIPyV prevalence in children with acute respiratory disease was also carried out. Two of the 126 samples obtained from the 31 hematopoietic transplant recipients were positive for KIPyV (1 sample, 0.79%) and WUPyV (1 sample, 0.79%). Both samples were obtained 15 days after allogeneic transplantation and virus persistence was not observed in subsequent samples. In symptomatic children, 7 of the 486 nasopharyngeal aspirates were positive for WUPyV (1.4%) and 1 for KIPyV (0.2%). Single polyomavirus infection was detected in four patients, whereas the remaining patients were co‐infected with respiratory syncityal virus (three patients) or adenovirus (one patient). The results suggest that WU/KIPyVs have a limited circulation in Italy and a low pathogenic potential in young children. Brief and asymptomatic infection can occur in hematopoietic transplant recipients. J. Med. Virol. 82:153–156, 2010. © 2009 Wiley‐Liss, Inc.

Long-Term Outcome of Children with Acute Myeloid Leukemia in First Remission Given Allogeneic HSCT from a Matched Family Donor After a Conditioning Regimen Comprising Busulfan, Cyclophosphamide and Melphalan.

Abstract 2288Poster Board II-265 Background.More than 80% of children with de novo acute myeloid leukemia (AML) achieve complete remission (CR) after aggressive induction chemotherapy. However, post-remission treatment plays a crucial role in the final outcome of these patients. In this regards, possible post-remission treatments include high dose chemotherapy, as well as autologous or allogeneic hematopoietic stem cell transplantation (HSCT).In the last years, several groups have compared allogeneic HSCT with chemotherapy or autologous HSCT in adults as well and children with AML in first remission. These studies have demonstrated that allogeneic HSCT is superior to the other forms of post-remission therapy in children with AML not carrying favourable cytogenetic characteristics.We herein report the long-term results of a prospective multicenter study aimed at evaluating the safety and efficacy of an original combination of 3 alkylating agents, busulfan (BU), cyclophosphamide (CY) and melphalan (L-PAM) as conditioning regimen for patients affected by de novo AML other than the FAB M3 subtype and given allogeneic HSCT from a matched family donor in first haematological CR. Patients and methods.Seventy consecutive patients (40 males and 30 females), affected by de novo AML in first CR, received an allogeneic HSCT from a HLA-matched family donor after a conditioning regimen combining BU (4 mg/Kg/day for 4 days), CY (60 mg/Kg/day for 2 days) and L-PAM (140 mg/m2). BU dosage was adjusted after the pharmacokinetic study performed following the first administration, in order to maintain a concentration to the steady state (Css) comprised between 600 and 900 ng/mL.Transplants were performed in one of the transplant centers of the Italian Association for Pediatric Hematology / Oncology (AIEOP) between 1992 and 2002.Median patient age at HSCT was 7 years (0.5 – 17). Two patients had FAB M0 AML, 25 M1, 17 M2, 12 M4, 21 M5, 1 M6 and 2 M7 AML. Children with M3 AML were excluded from the study. Five patients with CBF anomalies, either isolated or associated with loss of sex chromosome, were considered to have favourable cytogenetics. The median interval between diagnosis and HSCT was 3.9 months (2.9 - 9). All patients were given bone marrow stem cells. GVHD prophylaxis consisted of cyclosporine-A (Cs-A) alone in 89% of patients, the remaining children receiving a combination of Cs-A with short-term methotrexate. Results.Median follow-up for surviving patients is 9 years (range, 6 – 16 years).The conditioning regimen was well tolerated, and no patient died for causes directly attributable to the myeloablative treatment.All patient engrafted, the median time to reach neutrophil and platelet recovery being 13 (7 - 28) and 21 (13 – 115) days, respectively.The cumulative incidence (CI) of grade II-IV acute GVHD was 58% (48 – 71), while that of grade III-IV acute GVHD was 14% (8 – 25). Chronic GVHD incidence was 27% (18 – 39).Ten-years survival probability was 77% (67 - 87), while 10-years disease-free survival (DFS) was 76% (65 - 86). The cumulative incidence of relapse was 17% (10 – 29), while the cumulative incidence of transplant-related mortality was 7% (3 – 17). Results improved over time, DFS being 59% (41 – 78) for patients transplanted before 1997 and 86% (75 – 96) for those transplanted after 1997. No other variables influenced the probability of both survival and DFS. Conclusions.Our study, conducted on a significant number of children affected by AML in first CR and with a very long follow-up demonstrate that allogeneic HSCT from a matched family donor can cure a large proportion of patients. The combination of dose-adjusted BU, CY and L-PAM was safe and well tolerated, with an incidence of TRM of only 7% and no death directly attributable to the conditioning regimen. Furthermore, the combination of 3 alkylating agents showed a good anti-leukemic activity, the probability of leukaemia recurrence being only 17%. Disclosures:No relevant conflicts of interest to declare.

The Significance of Hepatic Iron Overload in Allogenic Stem Cell Transplant Recipients.

Abstract 4313 IntroductionIron overload has increasingly been recognized as a cause of morbidity and mortality among allogenic hematopoietic stem cell transplant (HSCT) recipients. Estimation of liver iron is considered the gold standard method that reflects the overall body iron burden. AimWe attempted to correlate the severity of liver iron overload to various clinical parameters in allogenic HSCT recipients. MethodsWe studied 49 adult allogenic HSCT recipients who had a minimum of one liver biopsy performed after transplant. All patients had been diagnosed, transplanted and followed up in our institution since 1998. Biopsies were performed due to abnormal liver function tests under the initial clinical suspicion of GVHD with a mean of 185 days (range: 23-844 days) post-transplant. Sections from each biopsy were stained with hematoxylin and eosin, Masson trichome and Perl's iron stains. We used the histological semiquantitative grading of liver iron (grade 0-4), evidence of GVHD (score 0-3) and fibrosis (stage 0-4). Iron overload was defined as a score of 2 and above (correlating with hepatic iron concentration >1.4 mg/g dry weight). Various clinical parameters were also assessed including age, sex, underlying malignancy, number of transfusions, source and type of stem cell transplant, liver function tests, clinical grading of GVHD, significant bacteremia, other infections, survival and cause of death. ResultsIn this cohort, 28 of 49 patients had iron overload. The overall prevalence of iron overload was 57% (95% confidence interval, 42%-71%). Iron overload in 7 of the 49 patients (14%) was the only histological explanation of liver dysfunction. The degree of iron overload was directly correlated to the number of transfusions (r=0.69, p<0.001), serum ferritin (r=0.55, p=0.004) and the development of significant bacteremia (r=0.33, p=0.019). The correlation to the histologic liver-GVHD grade was close to statistical significance (p=0.062). 37 of the 49 patients (76%) died after HSCT at a mean of 677.8 days (range: 52-3821 days) post-transplant. The overall mortality did not correlate statistically to the degree of iron overload. The mortality was higher in patients with high serum bilirubin (direct or total) and increasing clinical degree of acute GVHD. Sixteen patients died secondary to infection (bacterial=15, fungal=1). However, there was no significant evidence of increased risk of infection-related mortality with iron overload (Hazard Ratio = 1.16, 95% CI, 0.76-1.77, p = 0.496). ConclusionIron overload is a common adverse effect of allogenic HSCT (57% prevalence). Iron overload occurred in some of our patients after as few as 10 red blood cell units. In this cohort, iron overload statistically correlated to the number of transfusions, development of significant bacteremia and clinical acute GVHD. We did not find a statistically significant association with mortality, likely due to our small sample size and complex clinical picture. Iron overload was the only histological explanation of abnormal liver functions in 14% of our patients. More studies are needed to determine the impact of iron overload in long-term morbidity and mortality in allogenic transplant patients. Disclosures:No relevant conflicts of interest to declare.

T-Cell Large Granular Lymphocyte (T-LGL) Expansion Post Adult Allogeneic Hematopoietic Stem Cell Transplantation (HSCT) – ‘A Prognostic Indicator for Improved Overall Survival'.

Abstract 2241Poster Board II-218 Introduction:T-LGL has the phenotype characteristics of a post-thymus mature T cell. Expansion of T-LGL has been reported to occur in association with viral infections, autoimmune diseases, lymphoproliferative malignancy and HSCT. The clinical significance of finding T-LGL expansion post HSCT is unclear. We recently reviewed the incidence of T-LGL expansion in patients who underwent allogeneic HSCT in our institution. We specifically asked whether T-LGL expansion was associated with increased viral infections, stable chimerism, graft-versus-host disease (GvHD), recurrence of primary disease, and overall survival. Patients and Methods:A retrospective analysis was done on all adult patients who underwent allogeneic HSCT at the Karmanos Cancer Institute between January 1, 2004 to June 30, 2009. In patients with persistent lymphocytosis (>3000 cells/mm3) post HSCT, expansion of T-LGL phenotype was identified by flow cytometry (CD2, CD3, CD5, CD7, CD8 and CD57 positive) and clonality was confirmed by T cell receptor beta and/or gamma gene rearrangement (TCR-GR) using southern blot analysis and polymerase chain reaction (PCR). Results:A total of 547 patients underwent allogeneic HSCT during the study period. We identified T-LGL expansion in 24 patients with persistent lymphocytosis using flow cytometry. Median age of patients with T-LGL expansion was 50 years (range 24-68 years). Median time to diagnosis was 275 days post HSCT (range 69-1454 days) and median duration of follow-up was 811 days (range 85-1701 days). All 24 patients achieved full donor chimerism post transplantation by STR analysis. Fourteen out of 24 patients with T-LGL expansion had positive TCR-GR, in 2 patients TCR-GR was not done and the remainder was negative. Twenty out of 24 patients had cytomegalovirus (CMV) viremia confirmed by PCR before the onset of T-LGL expansion; the remainder had no CMV viremia. In all patients with T-LGL expansion there was no subsequent recurrence of CMV viremia or infection. All 24 patients had documented graft versus host disease (GvHD). In the group with T-LGL expansion only 2 patients relapsed with primary disease and only one patient died (due to a cardiac event). The cumulative incidence of T-LGL expansion was 4.4% at the end of the study period. Conclusion: To our knowledge, this is the largest reported series of T-LGL expansion post allogeneic HSCT. T-LGL expansion was associated with an interesting sequence of CMV viremia preceding T-LGL expansion and subsequent lack of recurrence of CMV viremia or infection. We also observed a very low number of relapse of primary disease or death in patients with T-LGL expansion. One hypothesis is that T-LGL expansion may be a result of specific stimulation with CMV antigens post allogeneic HSCT. An alternate hypothesis is that T-LGL expansion is a surrogate marker for accelerated immune reconstitution. At present, it is also unclear if T-LGL expansion is a marker of ‘graft-versus-leukemia' effect with respect to relapse of primary disease warranting further research.T-LGL expansionTCR-GR PositiveTCR-GR Negative/Not doneNo. of patients1410Type of transplantationUnrelated 6 ; Related 8Unrelated 7 ; Related 3Pre-transplantation diagnosisAML 3AML 4NHL 5NHL 2CLL 2ALL 2ALL 3CML 1MM 1MM 1GVHD ProphylaxisTAC/CELL 11TAC/CELL 9CSA 1ATG/TAC/SIRO 1ATG/ TAC/ SIRO 2CMV statusD-/R+ 8D-/R+ 3D+/R+ 6D+/R+ 6D+/R- 1CMV viremia by PCRPositive 13; Negative 1Positive 7; Negative 3GVHDPresent 14; Absent 0Present 10; Absent 0Median lymphocyte count at diagnosis (cells per mm3)3900 (range 1600-16,800)4000 (range 3100-8600)Median time to diagnosis (Days post HSCT)188 (range 69-1280)575 (range 154-1454)AML- Acute myeloid leukemia; NHL- Non-Hodgkin's lymphoma; CLL- Chronic lymphocytic leukemia; ALL- Acute lymphocytic leukemia; MM- Multiple myelomaTAC- Tacrolimus; CELL- Mycophenolate mofetil; CSA- Cyclosporine; ATG- Anti-thymocyte globulin; Siro- Sirolimus Disclosures:Lum:Transtarget Corporation: Founder

High Incidence of Invasive Fungal Infections in Adult Patients Undergoing Hematopoietic Stem Cell Transplantation.

Abstract 1136Poster Board I-158 IntroductionInvasive fungal infections (IFI) are associated with significant morbidity and mortality in hematopoietic stem cell transplant (HSCT) patients. Prophylaxis of high risk patient groups has become a key strategy in managing these infections, which are characteristically difficult to pre-emptively diagnose. The benefit of newer prophylactic agents depends in part on the local incidence of IFI in a population. This study was carried out to define the incidence of IFI in a cohort of HSCT patients treated by the Leukemia/Bone Marrow Transplant Program of British Columbia, to elucidate risk factors for IFI and to assess the efficacy of our current prophylaxis strategy. MethodsTwo hundred and forty-nine adult HSCT patients who underwent autologous or allogeneic transplantation between October 2006 and March 2008 were retrospectively evaluated. One hundred and eighty patients underwent high dose chemotherapy and autologous HSCT during this period. The indication for HSCT in this group was predominantly multiple myeloma (n=95; 53%) or non-Hodgkins lymphoma (n=59; 32.8%). Sixty-nine patients underwent allogeneic HSCT using a related sibling (n=46) or matched unrelated (n=23) donor. The predominant indication for allogeneic HSCT was acute leukemia/ myelodysplasia (48%), followed by non-Hodgkins lymphoma (25%) and chronic lymphocytic leukemia (12%). Patients enrolled in prophylaxis clinical trials or with previously documented IFI were excluded from analysis. Routine antifungal prophylaxis with low dose amphotericin B (10mg/m2/day) for inpatients and oral fluconazole (400mg/day) for outpatients was given during the neutropenic phase throughout the period of the study. ResultsThe overall incidence of proven, probable or possible IFI was 2.2% (4/180) and 19% (13/69) in autologous and allogeneic HSCT groups, respectively. The median time to IFI in autologous HSCT recipients was 12.5 days (7-19) post transplantation. In allogeneic HSCT patients, a bimodal incidence of IFI was observed with the first peak occurring within the first 30 days of transplantation and a later peak after 100 days. Invasive aspergillosis (IA) was the predominant IFI encountered (82%); the remaining IFI were due to invasive candidiasis (IC). The incidence of IA was 1.7% (3/180) and 16% (11/69) in autologous and allogeneic HSCT patients. Mortality attributable to fungal infection was 18% (3/17) and all deaths were cases of IA occurring in the allogeneic HSCT group. Modification of antifungal prophylaxis occurred in 23% of patients. Indications for changes in prophylaxis included: initiation of empiric therapy for suspected infection (18%), change to an orally active agent to facilitate discharge from hospital (12%), nephrotoxicity (14%) or infusion reactions (2%). Patients who developed IFI were more likely to have received prolonged high-dose corticosteroid therapy (i.e. prednisone >7.5mg daily for 3 weeks or more) for graft-versus-host disease (82% in IFI vs. 24% in non-IFI, p<0.001). Patients who received alemtuzumab or fludarabine as part of the conditioning regimen were also more likely to develop IFI (23% in IFI vs. 1.3% in non-IFI, p<0.001) and (23% in IFI vs. 6% in non-IFI, p=0.005), respectively. IFI patients were more likely to have received total parenteral nutrition during the peritransplant course (47% in IFI vs. 18% non-IFI, p<0.001). ConclusionInvasive fungal infections occurred in 19% of allogeneic HSCT recipients with an attributable mortality of 18%. IFI is less concerning in autologous HSCT recipients, occurring in 2% of cases. The predominant infection of concern is invasive aspergillosis in our population. Patients should receive prophylaxis during the neutropenic phase following allogeneic HSCT; those who develop graft-versus-host disease requiring prolonged steroid therapy should be particularly targeted for antifungal prophylaxis with mould-active antifungal agents. The role of T cell suppression in conditioning therapy and the influence of TPN exposure on the incidence of IFI is an area which warrants further study in defining specific risk groups for costly and potentially toxic prophylactic therapy. DisclosuresNo relevant conflicts of interest to declare.

Primary Antifungal Prophylaxis in Adult Hematopoietic Stem Cell Transplant Recipients: Current Therapeutic Concepts

In recipients of hematopoietic stem cell transplants (HSCTs), the mortality associated with invasive fungal infections (IFIs) remains high, despite the introduction of broad-spectrum antifungal agents over the past 2 decades. Preventing exposure to fungal pathogens in this population is impossible; therefore, clinicians have focused on prophylactic use of antifungal agents to prevent IFIs in high-risk HSCT recipients. It is important to target antifungal prophylaxis by type of HSCT (autologous or allogeneic), local epidemiology, and risk factors for IFIs so that patients can receive the most appropriate agent while balancing costs and the risks of toxicity, and minimizing the development of resistance. To assist clinicians in weighing the pros and cons of currently available antifungal agents when choosing a suitable prophylactic regimen, we provide a review of several key prospective randomized trials that evaluated various antifungal agents for primary prophylaxis in adult HSCT recipients. In addition, we describe the epidemiology of and risk factors for IFIs in HSCT recipients, the difficulties in diagnosing IFIs, antifungal agents used for prophylaxis, and the goals of primary prophylaxis. Fluconazole remains the gold standard for primary prophylaxis in autologous HSCT recipients. For allogeneic HSCT recipients, the agent chosen for prophylaxis must be based on the patient's risk factors for IFIs. In low-risk patients, fluconazole is an appropriate agent to use for primary prophylaxis immediately after transplantation. However, in allogeneic HSCT recipients who develop complications, such as graft failure, graft-versus-host disease, or cytomegalovirus infection, prophylaxis with a mould-active agent should be used.

Hepatic Safety of Voriconazole after Allogeneic Hematopoietic Stem Cell Transplantation

Voriconazole is increasingly used in allogeneic hematopoietic stem cell transplantation (HSCT) for prophylaxis and treatment of fungal infections. Hepatic dysfunction is common in patients undergoing HSCT and may have an impact on the clinical decision to institute voriconazole. We conducted a retrospective review of all adult and pediatric HSCT recipients who received >2 consecutive doses of voriconazole between January 2005 and February 2008. Clinical hepatotoxicity was defined as the subjective attribution of liver enzyme elevation (even a mild one) to hepatotoxicity because of voriconazole by the treating physician and leading to discontinuation of voriconazole. Biochemical hepatotoxicity was defined as an elevation in one or more liver enzymes to >3 times the upper limit of normal or >3 times the baseline value if abnormal at baseline. Liver enzymes assessed included aspartate aminotransferase, alanine aminotransferase, alkaline phosphatase, and total bilirubin. Simple and multiple logistic regressions were used to define the risks for hepatic dysfunction. The Wilcoxon signed-rank test was used to assess the differences in liver function test values before, during, and after the use of voriconazole. Sixty-eight of 200 patients (34%) developed hepatotoxicity while on voriconazole. The median duration of voriconazole therapy was 72 days (range, 1-804 days). Biochemical hepatotoxicity occurred in 51 patients (75%); clinical hepatotoxicity, in 17 patients (25%). Thirty-five (51%) of the patients with hepatotoxicity required discontinuation of therapy. In simple logistic regression, acute graft-versus-host disease (GVHD) was a risk factor for hepatotoxicity, and receipt of a T-cell depleted allograft was protective. In multiple logistic regression, acute GVHD (P = .002) remained significant. There were no cases of liver failure or death attributed to voriconazole. In this cohort of patients undergoing allogeneic HSCT, the rate of hepatotoxicity while on voriconazole was 34%. In general, the hepatic dysfunction was mild and reversible. Voriconazole therapy with monitoring appears to be reasonably safe for use in HSCT recipients at high risk for invasive fungal infections.

Allogeneic Hematopoietic Stem Cell Transplantation and Norovirus Gastroenteritis: A Previously Unrecognized Cause of Morbidity

A retrospective study of the clinical, epidemiologic, and virologic features of norovirus gastroenteritis in 12 adult allogeneic hematopoietic stem cell transplant (HSCT) recipients. Norovirus infection was diagnosed by reverse-transcriptase polymerase chain reaction. Strains were genotyped by nucleic acid sequence of the most highly conserved region of the norovirus gene encoding the capsid S (shell) domain. Ten of 12 patients presented with vomiting of short duration, but diarrhea was present in all. The median time from onset to norovirus diagnosis was 1 month (range, 0.25-6.0 months). Eleven patients were receiving immunosuppression when norovirus infection was diagnosed: 8 for graft-versus-host disease (GVHD) in an organ other than gut, 1 for previous gut GVHD, and 2 for presumed gut GVHD that proved to be norovirus gastroenteritis. Six patients required enteral or parenteral nutrition for severe weight loss. In 10 patients, diarrhea lasted a median of 3 months (range, 0.5-14 months) and virus was shed at a high level throughout. The remaining 2 patients died after 4 months of diarrhea (one died of unrelated complications, and the other died of malnutrition). The noroviruses found were GII (untyped), GII-3, GII-4, and GII-7 in 1, 1, 9, and 1 patients, respectively. Eleven of the 12 patients had acquired their infection in the community. Phylogenetic analysis of the GII-4 strains demonstrated that all differed. Noroviruses are a hitherto unsuspected cause of prolonged morbidity and mortality in adults after allogeneic HSCT. The use of reverse-transcriptase polymerase chain reaction to detect high viral load levels in feces distinguishes norovirus gastroenteritis from gut GVHD.